The Alliance for Health Policy & Systems Research, a global partnership hosted within WHO, is about to launch a new implementation research programme focused on results-based-financing (RBF). A few experts of the Performance Based Financing Community of Practice (CoP PBF) attended a preparatory meeting in Geneva on 23-24 January. In this blog post, they report on the two-day event.

 The Alliance for Health Policy & Systems Research is known for its commitment to enhancing the dialogue between researchers and research users, policy makers in particular, in developing countries. As readers of this website know, the Harmonization for Health in Africa communities of practice fully embrace this agenda. Late December, several of us were contacted by Joe Kutzin (WHO, Geneva - Department of Health Systems Governance and Financing) and Nhan Tran (Alliance) to join them, together with other RBF and provider payment reform experts, for a consultation meeting to prepare a new call dedicated to implementation research on RBF. Olivier Basenya, Por Ir, Bruno Meessen and Laurent Musango made the trip to Geneva.

Participants were asked to assist the Alliance in identifying main implementation research questions related to the scale up and integration of RBF initiatives into national health systems and policies, and in identifying priority countries where such research would have a greater impact. After two days of intense interactive deliberations, it was decided that the research program will focus on the enabling factors and barriers for RBF (pilot) schemes to be scaled up and integrated into national health systems and  policies, taking into account RBF design features and implementation process, health systems characteristics, and socio-economic and political context. We agreed that the importance (extent) of the scaling-up and integration would  be assessed on several dimensions such as population and service coverage, institutionalization, financial integration in the public budget and so on. While some countries have been relatively successful in making progress on this multidimensional scale, others have been encountering quite serious obstacles in doing so.We are hopeful that this research program will bring interesting insights into how one needs to successfully navigate the policy process, combining efficiency with ownership and a sufficiently inclusive process, with the aim of strengthening health system and moving towards Universal Health Coverage (UHC). We know from previous meetings that national PBF champions are looking for guidance in this respect.

All participants made relevant contributions, with some as delicate as the tiny paper cranes produced by Professor Winnie Yip from Oxford University (picture illustrating this blog post). Others (like ourselves),  conveyed their message in a more straightforward way. One of the things we emphasized was that it’s vital to ensure that the research process involves country health authorities in such a way that it allows them to reflect on the extent to which they have actually achieved health systems strengthening via the integration/scale up of their pilot schemes – a shift from scheme to system and policy.

Interestingly enough, the research program will not have a purely instrumental aim. Eligibility criteria will also allow applications by research teams willing to document processes which were wrong from the start, e.g. a pilot project with insufficient or no (government) ownership,  or one that failed to be scaled up. It was suggested that the research areas should be a mixture of countries that have advanced in RBF implementation at national level, countries in pilot experiences phase and some others with a demand side component. 

The planning of the Alliance is ambitious. We expect the call to come out soon, so keep an eye on their website (ourselves, we will of course inform CoP experts through our online forum). We hope that many of you will apply and submit letters of intention as this is a research program fully in line with priorities pursued by the PBF CoP.

In this blog post, Isidore Sieleunou (co-facilitator of the "Financial Access to Health Services" Community of Practice) summarizes some of the main messages of the conference which took place in Ouagadougou (25-28 November 2013). The event was co-organized with the FEMHealth Consortium and the universities of Heidelberg and Montreal. This blog post is cross-posted from the IHP newsletter.

In 2011, the Financial Access to Health Services Community of Practice (FAHS CoP) held a workshop in Bamako to discuss the formulation and implementation of maternal health fee exemption policies. At the end of the workshop, a research agenda was put forth. Two years later, the FAHS CoP, alongside several academic partners, gathered again to take stock, this time in Ouagadougou, Burkina Faso.

A conference to assess the effectiveness of fee exemption policies

This time, our focus was on evaluating the effectiveness of these policies. Have they had a positive impact on maternal health? Have they had a protective effect on households against catastrophic health expenses? How well have they been integrated into health systems?

Plenty of stakeholders showed interest;  more than 120 participants gathered in Ouagadougou:  high-level decision makers, front line implementers of fee exemptions, researchers, and representatives of both bilateral and multilateral, governmental and non-governmental institutions.

It turned out to be an exciting week of activities structured in an innovative 1+3+1 format (field visit on the first day, then 3 days of presentations and debates, and a training session on the last day, with each person free to choose the program of events that suited him/her). A clear highlight was the fact that the French Minister delegate for Development, Monsieur Pascal Canfin, and the Minister of Health from Burkina Faso, Monsieur Léné Sebgo, presided over the conference’s closing session – a major political recognition for our CoP! 

Policies that are working

For more than 10 years now, numerous African countries have launched fee exemption policies in an effort to achieve the MDGs, but also to reduce out-of-pocket health expenditures.

Content wise, these policies vary from one country to another. The policy in Benin, for example, covers only Caesarean sections, while Burkina Faso’s policy extends coverage to all services during the pregnancy and neonatal period, albeit with a patient co-payment equivalent to 20% of direct costs.  In between these two cases, there is a range of combinations.

A lot of the discussions in Bamako focused on the fact that most of the policies were hastily implemented at the national level, without the benefit of a pilot phase, without adequate accompanying measures, and especially without systematic monitoring and evaluation of the impact.

This situation has posed plenty of methodological challenges for researchers, but nonetheless, a number of research programs were undertaken, and against all odds, several research teams managed to document these policies. In recent years, managers and implementers of these policies have accumulated significant tacit knowledge.

The study results presented in Ouagadougou are impressive, and show that exemption policies and subsidies have:

• Resulted in higher utilisation of maternal health services, such as prenatal care and assisted deliveries;

• Shown that insofar as many wealthier women already sought out such maternal health services, the rise in utilisation is particularly obvious for poorer women. This is especially documented in the cases of Burkina Faso and Morocco; 

• Led to better access to Caesarean sections with a reduction in post-Caesarean mortality and a significant reduction in unmet need for obstetric services in Benin, Burkina Faso, Guinea and Morocco (though in terms of the quality of the services delivered, there is some variance, as shown by a FEMHealth study in Benin);
• Lessened household out-of-pocket payments for maternity care in Burkina Faso and in Morocco.
  

We noted the interesting effect on women in one district in Burkina Faso of strengthening their decision-making power within the household (by eliminating the financial worry and providing a clear care-seeking path). Another effect was faster health seeking behaviour among women and their children.

But of course, difficulties remain, and some of the results are mixed. One study documented the problem of health worker overload in Niger. It also appears that in Benin richer women benefit the most from the free Caesarean section policy.

These challenges are most likely not inherent to the fee exemption per se, but to deficiencies in the policy’s formulation and/or implementation within the health system. Implementation challenges are unavoidable, though, and countries are learning as they go.

The clear success of the policy in a country like Burkina Faso is also directly linked to its monitoring and evaluation – its ability to produce data and use these data to adjust policy implementation accordingly.

What is in store: a new generation of more targeted fee exemptions?

In my view, the debate should no longer center on whether one is “for or against” fee exemptions, but should take a country-by-country approach instead.

In countries where fee exemptions and subsidies are working -  if the rate of assisted deliveries is high (Burkina Faso and Morocco) - or in a country where those rates were already high (Benin), it is probably time to think about the next step, “second generation models”, where several financing schemes are used in tandem to address a specific challenge.

One example is the inadequacy of exemption policies to reach some vulnerable population groups, who may face other as yet insurmountable obstacles to actually reaching a health facility. I still remember the words of a doctor from Kaya regional hospital during the field visit; “I cannot understand: services are free, but women are still not coming.” 

Given the example of the success and effectiveness of “vouchers programs” on utilisation, quality, and equity (an example from Kenya was presented at the conference), it could be interesting, for example, to pair a fee exemption with a “voucher” for the poorest women. Such a combination could strengthen fee exemption policies and make them more effective in terms of reaching the poorest and most vulnerable groups.

This conference also sounded like a (necessary) response to the recent Bonn forum on universal health coverage (UHC). During this three-day forum, a wide range of strategies targeting all dimensions of UHC (population coverage, access, and financial protection) were discussed from efficient service purchasing to insurance systems, from cash transfers to vouchers … just no mention of user fee abolition. UHC is all about responding to increasing demands for better health services, no matter what path towards the goal is chosen, keeping open all policy options, adjusting to the specific circumstances of each country. Exemption/subsidy policies are proven and cannot be left out of instruments for UHC in Africa.

In their closing words at the conference, the French Minister delegate for Development and Burkina’s Minister of Health paid tribute to the CoP’s dynamic approach, emphasizing the importance of substantive exchange among different knowledge holders in order to overcome challenges and succeed in health system reform.

Allison Kelley

In this blog post, Allison Kelley presents a descriptive research project being carried out by experts from two communities of practice – Financial access to health services and Performance-based financing - in twelve Francophone African countries.  One of the project’s innovations is its collaborative approach.

Universal health coverage (UHC) – is higher than ever on the agenda, both nationally and internationally. Presidents, key development partners, and even international NGOs are all pushing for UHC. What consensus! And yet – as is often the case – the devil is in the details – and in this case, in the many and ever expanding number of health financing schemes in African countries: user fees, budget allocation, funding inputs, community-based health financing schemes, fee exemptions for certain population groups, exemptions for the poorest, performance-based financing… Just to illustrate my point, one of our experts has already inventoried 29 different health financing schemes in Niger!

Such fragmentation in national health financing, without even mentioning the challenges of quality and human resources, can leave one feeling perplexed in the face of all the fervour around UHC.  How can the various pieces of the health financing puzzle be assembled to constitute a coherent picture at a national level? In many countries, there are a multitude of different actors involved in the planning and implementation of such health financing schemes (HFS), all with their own objectives. Many are unaware that they are in some way contributing to UHC in their country. They may also be lukewarm at the prospect of collaborating or being “rolled up” into some sort of larger scheme.

The diversity and confusion around various aspects related to the governance, objectives, intervention level, target groups, financing sources, available budgets, eligibility criteria, management and performance of these various HFS are such that no one today has the whole picture. And yet this picture would seem essential if a country truly wants to progress toward a more efficient and equitable national health financing system. It would also help to identify population groups that are less well covered, and those that may have double coverage (and those who stand to gain from such double coverage), inefficiencies, etc. I’d even suggest that having this full picture should be a prerequisite to defining and putting in place a national health financing strategy.

A multi-country study

Thanks to French Muskoka funding (with additional resources from Cordaid), experts from two CoPs – financial access to health services and performance based-financing – are carrying out a collaborative research project in 12 sub-Saharan Francophone African countries. Their goal is to map this tangle of HFS.  At the country level, we hope that this mapping exercise will create a clearer picture of the complexity of health financing schemes in-country. By comparing across the 12 countries we hope to be able to begin to trace some recurrent situations, or patterns, that we can interpret as favourable or unfavourable (using existing knowledge of health economics and political economy) toward expanding UHC.  

A collaborative process from A to Z

If this research is modest in terms of its scientific objectives (descriptive documentation only using existing secondary data and knowledge held by experts), it is more innovative from a methodological perspective: from its conception to its end, it is a collaborative process. 

Back in Spring 2012 (yes, it can take some time to turn an idea into a reality…), we organised a “virtual brainstorming” using the on-line discussion groups of two CoPs. We asked members to suggest priority research topics for a proposal to be submitted for French Muskoka funding (UNICEF WCARO). We then put the suggested topics to an electronic vote by members. The outcome was uncontested: the top priority topic was to better understand how to link up the ever-growing number of HFS at the national level in a coherent move toward UHC.

Since so many countries were interested in the topic, we opted for a more open research model that would capture a maximum number of experiences (rather than focus in on 1-2 countries): a sort of overview of what exists, not unlike the inventory carried out to prepare for the FAHS CoP’s first workshop in Bamako. We launched a call for individual experts to carry out the research at the country level. Because the Muskoka funding covered francophone countries (and only some of those at that), we ended up with candidates for 10 countries: Benin, Burkina Faso, Guinea, Ivory Coast, Mali, Niger, Central African Republic, Democratic Republic of the Congo, Senegal, Chad, and Togo. Our open model then led us to include two “non-Muskoka” countries, Burundi and Cameroon, thanks to Cordaid funding.

After signing the contract in Spring 2013, we were able to thus put the research team in place. A study guide was drawn up and shared with this team, and then improved through their comments and suggestions. A product of real joint collaboration!

What’s next

The research is finally underway. Researchers on the team are in continuous discussion on challenges, tips, and strategies for obtaining the financial data they need…

The results from this first phase of research – a mapping of HFS in 12 countries and a synthesis of the situation across these countries – will be presented at the March AfHEA conference in Nairobi shared more broadly by mid 2014.  This picture of almost a quarter of the countries in Africa should suggest some more general lessons and perhaps even some recommendations.

In early 2014, we will begin preparing the second phase of the research (to take place in 2014-15). Our intention is to develop a more in-depth questionnaire that we will test in at least one country. Phase 2 will thus take a “deep dive” in a number of countries (providing sufficient funding is available). We will attempt to document efficiency and equity losses due to overlapping and duplicative HFS and to identify areas for improvement. We expect that this second phase will produce concrete recommendations for each country studied in-depth.

This type of research project is definitely uncharted territory for the CoPs. Its the first time we have solicited member involvement for this sort of documentation. What we find especially interesting is getting involved in an area of research that is relatively less popular – multi-country studies and cross-country analysis. Between individual studies on health financing in a particular country and the tables WHO produces annually on international health spending, we think there is room!  And CoPs may just have a role to play, given their members span almost every country on the African continent. Still, our ability to succeed at such endeavours will depend on factors like our ability to coordinate amongst ourselves, and to help each other out where necessary. We certainly plan to document this original, collaborative research model along the way.

So stay tuned for preliminary results in early 2014. Here’s hoping that we can contribute to making more of the existing multiple and diverse HFS to expand UHC.

Bruno Meessen

In this blog, Bruno Meessen (ITM, Antwerp and facilitator of the PBF CoP) shows how Results Based Financing could be a lever for African governments in the battle for family planning …  and even more so, when other influential actors in society are hostile.

On sticks, carrots and sermons

Whether you are a general, the leader of a gang, the boss of a big company, or a parent desperately trying to maintain authority, you have three main instruments to steer the behavior of your fellows and subordinates: sticks, carrots and sermons.

The metaphor of a ‘stick’ describes the variety of devices you have at your disposal to deter and, if necessary, punish behavior not in line with your objectives.  This is the fine a policeman gives you if he sees you driving without a seatbelt, for example, or the shot in the knee (at best) for the villain who betrays his boss, the non-renewal of a contract for a supplier due to poor service,… 

The ‘carrot’ is of course used as a metaphor for a reward. A medal for a brave soldier, for example, a diploma for a diligent student, the price paid to a baker for his delicious bread and of course, pay for performance, which I’m sure I don’t have to explain on this blog.

By ‘sermons’, we mean all strategies and tools of education and persuasion. Economists will tell you that these aim to change the preferences of economic agents. More prosaically, the aim is a situation where your fellows, convinced by the strength of your discourse, spontaneously adopt behavior aligned with your goals. This usually happens after you have offered convincing arguments, but if you also have a certain moral authority (like the mother has towards her child, the teacher versus his students, or the priest towards the parishioners), you have an additional advantage.

These tools all have their strengths and weaknesses, and need to be assessed in their particular situation. PBF experts, if they believe in the power of ‘carrots’, also know carrots can’t change all behaviors. ‘Sermons’ will be particularly useful when it’s impossible to verify behavior or when behavior that needs to be encouraged is also beneficial for the one adopting the behavior (example: usage of a condom). Note also that the times are changing: our societies cherish more and more individual freedom and responsibility. ‘Sticks’ are thus less and less tolerated and certain forms used in the past are now even prohibited by law.

Let's appreciate the opportunity offered by Results-Based Financing (RBF)

These are thus the three tools available to governments to influence the behavior of their citizens. In this respect, it is clear that RBF, by its very  nature, is a significant enrichment of the toolbox of African governments. But my wish is that they use this instrument in an even more strategic way, more in particular when they face other leaders promoting views contrary to their own vision of development.

Let’s give an example. Imagine a country which faces a serious demographic problem, to the extent that the high birth rate puts more and more pressure on the economy and more fundamentally, undermines the opportunities which could be available to citizens in the future. Imagine that the government has identified family planning by informed parents as a human right, on the one hand, and as a necessity to boost the development of the country, on the other hand. Imagine then that a prominent religious leader promotes a totally different vision … with a sermon, of course.

What should the government do in this case? Should it opt for the ‘stick’ (eg summon the hierarchy of the religious leader, with the threat of a sanction), or for a confrontation of ‘sermon’ (by the president) versus sermon (of the bishop, for example) on the issue at stake? If I were president of this (imaginary) country, I would think twice. If the bishop (for example) has dared to challenge you over this issue, it’s no doubt because he knows that the balance of power is not exactly in favor of you for the moment. At certain times in the life of a politician, a public confrontation on a particular topic can obviously harm his (or her) goals: the church he/she faces can be very powerful; moreover, given the church’s commitment to social sectors (schools, health centers, …) it will remain a partner for the government to work with. So it’s important to choose your battles – but this, we don’t have to tell politicians.

Results-Based Financing: a powerful lever for change

Faced with this situation, are you powerless then? Before RBF, this was probably the case. However, I think RBF now offers new and ‘smart’ opportunities for government action. The first option, if it hasn’t been implemented yet, is to add family planning to the grid of PBF of health centers (i.e. to reward the health centre for each new woman adopting a modern contraceptive method). If family planning indicators are already present, the government could increase reimbursement rates (as it has been done in Burundi late 2012). This may be powerful, but not enough, especially if many health facilities are affiliated to the church challenging your national policy! I supect that the real breakthrough will come from  involving the communities. First, the government could, like in Makamba (Burundi), contract community associations to refer women interested in family planning. But the government could go even further: it could decide to introduce a voucher system which would encourage women to adopt a modern contraception method. To distribute these vouchers in the community, we would mobilize of course the many female community health workers (with a small compensation for every woman they refer to the health center!). Being wives, mothers, sisters, friends and neighbors, I’m sure they would find the right words to convince their peers.  

By mobilizing the women in communities in Africa and tapping a peer-to-peer educational strategy, it seems to be me RBF can mobilize hundreds of thousands of very persuasive agents who can even beat seasoned preachers, if need be! 

Let us forward this message to political leaders of Africa.



Looking for more resources on RBF & family planning? 

Reproductive Health Vouchers: from promise to practice, T. Boler & L. Harris, 2010, Marie Stopes International.
Voucher schemes for sexual and reproductive health services: a Marie Stopes International (MSI) perspective, factsheet.
Can incentives strengthen access to quality family planning services? Lessons from Burundi, Kenya and Liberia, L. Morgan, 2012, Health Systems 20/20, USAID.  

Isidore Sieleunou (AEDES & co-facilitator of the CoP Financial Access to Health Services) interviews Anna Gorter on a recent evidence review she co-authored with Por Ir (National Institute of Public Health, Phnom Penh) and Bruno Meessen (Institute of Tropical Medicine, Antwerp). The review, commissioned by the German Federal Ministry for Economic Cooperation and Development, is accessible on the German Health Practice Collection website, here (together with other documents and power points).

Your literature review is timely for the hot debate on Result Based Financing (RBF). Could you summarize its key findings?

RBF is a relative new approach in health in Low and Low-middle-Income Countries (LLMIC). It is an answer to the disappointing results of the health sectors to meet public expectations and reduce maternal, neonatal and child mortality and morbidity. Many governments are aware of the low performance of their service providers and are ready to test new approaches health. As a result a wide range of approaches has been developed, whereby payment of providers is linked to the results providers achieve.

Our review focused on maternal and neonatal health care and on the effects on the performance of health care providers. We investigated four approaches: performance based financing (PBF), performance based contracting (PBC), vouchers, and Results Based Budgeting (RBB) (also named performance-based budgeting or intra-governmental transfers). We looked at utilisation of services, quality of services, and equity (i.e. if the approach was pro-poor, reducing the rich-poor gap in access to care). There were little or no studies on cost-effectiveness or sustainability. All in all we found 70 research papers for 37 programmes, of which 27 had a rigorous design and which were used for the final conclusions.  

The strongest evidence was found for vouchers, with robust evidence that vouchers can increase utilisation and quality of services, and improve equity. For PBF we found robust evidence that they can improve quality, but insufficient evidence for utilisation and equity. For PBC we found modest evidence for utilisation and equity and insufficient evidence for quality. For RBB there were not enough studies. Vouchers are a much older approach (since 1964), while PBF and PBC only started a decade ago, hence the difference in evidence.     

You have been working on the voucher approach for a substantial part of your career. Which place do you see for vouchers in Africa?

For me, vouchers have always been the tool par excellence to reach disadvantaged populations with critical services, such as mother and child care, family planning, STI and HIV care, cervical cancer, etc.  That is assisting the poorest or otherwise disadvantaged in using health services, which are important for their health, but which they are not using currently.

We developed the approach in 1995 in Nicaragua, basically to assist sex workers and adolescents to access sexual and reproductive health. We saw it as a way to overcome financial barriers as well as to improve the quality of care which was also an important barrier for these groups. The results were much better than we ever expected and that is when we started to analyse the reasons for this success. Vouchers provide strong incentives on the demand side (they inform, they guide, they empower the clients) as well as on the supply side (health providers are motivated to attract more clients and contracts demand also improved technical quality). 

I think that vouchers do have a place in Africa, especially in targeting those populations which are currently not reached and also in driving improvements of provision of services at the facilities. In the Kenya voucher scheme we have seen that providers invest the voucher revenue in improving the functionality of their facility and increasing their capacity (sending staff to be trained in long term family planning, repairing their buildings and ambulances, buying equipment, supplies, new maternity wards and operating theatres etc.). Vouchers could be used for especially critical services, where other approaches have not worked. 

In Africa, many countries have launched at the same time – sometimes in parallel – various health care financing approaches. Would it not make sense to merge them? Could you tell us what could be the effect of a combination of two or more RBF approaches, for instance PBF, Vouchers and even targeted free health services?

Combining PBF and vouchers would certainly increase the effectiveness of both approaches, although this has not be done so far. As described above, vouchers can bring in clients who need services but who even in the presence of a PBF still do not come to the health facility. Distributing the vouchers provides an opportunity to give face-to-face relevant information on particular health services and where these can be obtained. The voucher itself inspires confidence in the clients that they actually will be attended, and this is especially important for the poorest or otherwise disadvantaged groups, who often lack self-confidence. Furthermore, additional benefits can be added to the voucher such as payment of transportation costs if that is an important barrier.  In that sense, a voucher program on top of a PBF scheme would enhance equity and reduce the rich-poor gap. Vouchers are in fact free health services targeted to special needy groups.

You worked a lot in Central America and more recently in Asia. Several RBF schemes documented in your review are indeed from those continents. What can Africa learn from them?

I think the most important lesson observed in my work is that in each country I visited there are huge population groups who are in need of particular health services but not use them because the access barriers are simply too great to overcome. Vouchers can assist them to overcome these barriers, both barriers at the demand side as well as at the supply side. In fact I think an important reason for vouchers to be so effective in the above described effects on utilization, quality and equity is because they alter behaviour of clients and providers at the same time. However, taken into account the many successful PBF programmes in Africa, I think there is a new role for vouchers and that is bringing in those clients who still not come. This would make the PBF programmes stronger and more effective in increasing the health of the poorest and most disadvantaged groups in Africa.